Effect of Two Different Types of Fibers on the Fracture

Resistance of Endodontically Treated Molars Restored

with Composite Resin
Sulthan Ibrahim Raja Khana / Ramachandran Anupamab / Mohanavelu Deepalakshmic /
Kumarappan Senthil Kumard

Purpose: To compare the in vitro fracture resistance of endodontically treated molars with mesio-occluso-distal
(MOD) cavities restored with two different types of fibers.
Materials and Methods: Sixty extracted human mandibular first molars were selected for the study and ran-
domly assigned to six groups (n = 10). Group 1 served as the control. In groups 2 through 6, endodontic access
and standard MOD cavities were prepared. Following root canal treatment, group 2 was left unrestored. In group
3, the teeth were restored with composite resin (Venus, Heraeus Kulzer). In group 4, flowable composite resin
(Venus, Heraeus Kulzer) was used before restoring the teeth with composite resin. In group 5, leno-woven ultra-
high molecular weight polyethylene ribbon fiber (Ribbond) was inserted in the flowable resin in a buccal to lingual
direction, and the teeth were then restored with composite resin. In group 6, translucent glass fiber (Vectris,
Ivoclar) was adapted over the flowable resin in the bucco-lingual direction and restored with composite resin. The
specimens were stored in 100% humidity at 37°C for 1 day. Compressive loading of the teeth was performed
using a universal testing machine at a crosshead speed of 0.5 mm/min. The mean load necessary to fracture
the samples was recorded in Newtons (N). Data were subjected to analysis of variance (ANOVA) and Duncan’s
post-hoc test, where significance was set at p < 0.001.
Results: The highest and the lowest mean fracture strengths were found in sound teeth (1598.8 N) and un-
restored teeth (393.7 N), respectively. The mean load necessary to fracture the samples was 958.6 N in the
polyethylene ribbon group (group 5), 913.2 N in the glass-fiber group (group 6), 699.7 N in teeth restored with
flowable resin and composite (group 4), and 729.3 N in group 3 with composite resin alone. Statistical analy-
sis showed significantly higher fracture resistance of both the fiber groups compared to composite resin alone
(p < 0.001).
Conclusion: Both polyethylene ribbon and glass fiber under MOD composite restorations significantly increased
fracture strength with no statistical difference between the two groups. Therefore, both polyethylene- and glass-
fiber-reinforced composites can be used for access cavity restorations in teeth with weakened cusps.
Keywords: composite resin, endodontic therapy, fracture resistance, polyethylene fiber, glass fiber, molars.

J Adhes Dent 2012; 15: 167–171. Submitted for publication: 12.10.11; accepted for publication: 23.04.12
doi: 10.3290/j.jad.a28731

a Senior Lecturer, Department of Conservative Dentistry and Endodontics,

Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Idea,
hypothesis.
b
Senior Lecturer, Department of Conservative Dentistry and Endodontics,
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Ex-
perimental design, wrote manuscript.
c Senior Lecturer, Department of Conservative Dentistry and Endodontics,
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India.
Proofread manuscript.
d Professor and Head, Department of Conservative Dentistry and Endodontics,
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Con-
tributed to discussion.
Correspondence: Dr. Sulthan Ibrahim Raja Khan, Chettinad Dental College, De-
part of Conservative Dentistry and Endodontics, Rajiv Gandhi Salai, Kelambak-
kam, Chennai, 603103, India. +91-044-4742-8353, Fax: +91-044-4741-3343.
e-mail: dr.sulthankhan@gmail.com
T he restoration of a pulpless tooth is a challenging as-
pect of endodontic therapy, as the tooth is weakened
due to the loss of cusps, ridges, or the arched roof of
the pulp chamber.24,29 The strength of endodontically
treated teeth also depends on the design of the res-
toration and the type of restorative materials. An ideal
restorative material should not only restore and seal but
should also reinforce the defective tooth.
The advancements in adhesive technology and the
strength of newer composites have made it possible to
create a conservative and esthetic postendodontic res-
toration. The cusps of teeth that are etched, bonded and
restored with composite resin are mechanically splinted
together and thus reinforce the teeth.12 However, the
contraction of an extensive composite restoration due to

Vol 15, No 2, 2013 167

Khan et al
2 mm
1.5 mm
Composite
Resin
2.5 mm 1.5 mm
polyethylene
fiber
Fig 1 Schematic diagram of cross section of the tooth show-
ing fiber placement.
polymerization shrinkage affects the outcome of the final
restoration.4 To overcome the polymerization shrinkage in-
duced stresses, flowable composite resin has been used
to act as a stress breaker.15,32 With the development of
different types of fibers, such as polyethylene or glass
fiber, another option is available as stress relievers in
composite resin restorations.6 When reinforced with fib-
ers, composite resins show an increase in flexural modu-
lus and fracture resistance.30 However, the comparison
between the fracture resistances of different fibers has
not been adequately tested. The aim of the present study
was to compare the fracture resistance of root-filled mo-
lars with MOD preparations between teeth restored with
polyethylene fiber and glass fiber under composite resin.
MATERIALS AND METHODS
Sixty intact, freshly extracted human mandibular first
molars with complete root formation were selected for
the study. The teeth were free of caries, any previous
restorations, and preexisting fractures or cracks when
observed under transillumination. The teeth were then
stored in chloramine-T at 4°C and rinsed under water
prior to use. The teeth were randomly assigned to six
groups. Each group comprised 10 teeth.
Group 1: control; no cavity preparation or root canal
treatment.
Groups 2 to 5: Standard access cavities were pre-
pared in the teeth using a high-speed #245 bur (SS White;
Lakewood, NJ, USA) and water spray. The canals were
instrumented with K-files using a step-back technique and
RC EZ lubricant (D-TECH; Pune, India) and 5.25% sodium
hypochlorite irrigant. Apical preparation was performed to
size 35 for distal canals and size 30 for mesial canals,
and step-back preparation was done to size 70. Teeth
were obturated with 2% gutta percha (Dentsply DeTrey;
Konstanz, Germany) by cold lateral condensation using
AH plus sealer (Dentply DeTrey). After obturation, radio-
graphs were taken. The chamber was then cleaned and
168
excess sealer wiped off with cotton. Subsequently, mesio-
occluso-distal (MOD) cavities were prepared up to the
canal orifices in the teeth using a high-speed bur and
water spray. The thickness of the cavity walls was meas-
ured as 2 mm at the buccal-occlusal surface, 2.5 mm at
the cementoenamel junction, and 1.5 mm at the lingual-
occlusal surface and cementoenamel junction. These
measurements were made using a vernier caliper in all
the samples.
Group 2: MOD cavities were prepared and left unre-
stored.
Group 3: The cavities were cleaned and dried. The sur-
face of the cavity wall was etched with 37% phosphoric
acid etching gel (Prime Dental Products; Thane, India) for
15 s and rinsed with water for 15 s. The cavity surfaces
were gently blot dried. Bonding agent (Gluma, Heraeus
Kulzer; Hanau, Germany) was applied to the cavity sur-
face using a microbrush and light cured for 20 s using a
QTH light-curing unit (Astralis 7, Ivoclar Vivadent; Schaan,
Liechtenstein). The cavities were then restored with a
hybrid resin composite (Venus, Heraeus Kulzer) using the
incremental technique; each layer was light cured for 40 s.
Group 4: The cavities were cleaned and dried. The
cavity surfaces were etched and bonded as described
in group 3. The cavity surfaces were then coated with a
layer of low viscosity resin composite (flowable composite
resin, FCR) (Venus, Heraeus Kulzer) and cured for 20 s.
This low modulus liner was then covered with the same
hybrid resin composite using an incremental technique,
and each layer was cured for 40 s.
Group 5: The cavities were cleaned and dried. The
cavity surfaces were etched and bonded as described in
group 3. The cavity surfaces were coated with a layer of
low viscosity resin composite (FCR) as in group 4. Leno-
woven ultrahigh molecular weight polyethylene fiber (Rib-
bond, Ribbond; Seattle, WA, USA) was removed from the
package using cotton pliers. Care was taken not to handle
the fiber with bare hands or latex gloves. A piece of the
fiber 10 mm long and 3 mm wide was cut. The fiber was
subsequently coated with adhesive resin. Excess material
was blotted off with lint-free gauze. Then the fiber was
embedded inside the flowable composite on the buccal
wall, pulpal floor and lingual wall of the cavities before
curing (Fig 1). After light curing for 20 s, the cavities
were restored with hybrid composite as described above
using an incremental technique, where each layer was
light cured for 40 s.
Group 6: The cavities were cleaned and dried. The
cavity surfaces were etched and bonded as described in
group 3. The cavity surfaces were coated with a layer of
low viscosity resin composite (FCR) as in group 4. Sections
of pre-impregnated translucent glass-fiber mesh (Vectris,
Ivoclar Vivadent) 3 mm wide and 10 mm long were applied
over the uncured flowable composite to the buccal wall,
floor, and lingual wall of the cavities as in group 5. After
light curing for 20 s, the cavities were restored with hybrid
composite using an incremental technique, where each
layer was light cured for 40 s.
Next, all the teeth in the various groups were mounted
in self-curing acrylic resin using 5.1 cm x 5.1 cm custom-
The Journal of Adhesive Dentistry

made molds. Self-curing polymethyl-methacrylate resin
(DPI) was mixed in a glass dappen dish and poured into
the mold. The teeth were embedded in the resin up to the
level of the cementoenamel junction. After the resin had
set, the embedded teeth were removed from the mold.
The specimens were subsequently stored in an incubator
at 37°C in 100% humidity for 24 h. Fracture resistance
testing was done in a Instron universal testing machine
(Lloyds; Fareham, UK). The specimens were clamped onto
the machine. Compressive force was applied with a 6-mm
diameter stainless steel bar centered on the tooth. Each
sample was loaded at a crosshead speed of 0.5 mm/min.
In all cases the force was applied to the restoration touch-
ing the buccal and lingual cusps of the teeth. The test
machine’s software recorded the peak-loaded fracture.
The force necessary to fracture each tooth was recorded
in Newtons (N) for each sample and tabulated. This data
was then subjected to a one-way ANOVA and a post-hoc
Duncan’s multiple range test with p < 0.001.
RESULTS
Mean fracture resistance (N) and the standard de-
viation for each of the six experimental conditions are
presented in Table 1. The statistical analysis indicated
that the fracture resistance of group 1 was significantly
higher than other groups (p < 0.001). Group 2 showed
the least fracture resistance. In addition, there was no
statistically significant difference in the fracture strength
between groups 3 (dentin bonding system + composite
resin) and 4 (flowable composite). Teeth restored with
polyethylene and glass fibers (groups 5 and 6, resp)
showed increased fracture resistance when compared
with teeth restored with composite resin only (group 3)
(p < 0.001). No statistically significant differences were
found between groups 5 and 6.
DISCUSSION
Endodontically treated teeth often lose substantial tooth
structure from previous caries, pre-existing restorations,
and/or endodontic procedures. 1 This compromise of
architectural integrity results in reduced fracture resis-
tance of endodontically treated teeth, especially molars,
which are subjected to higher occlusal forces.
Root canal treatment should not be considered com-
plete until the coronal restoration has been placed. The
various techniques and materials used for the final res-
toration include complete cast coverage,13 indirect cast
restoration covering the cusps,24 complex amalgam res-
torations,27 and composite restorations.12 Adhesive res-
torations transmit and distribute functional stresses bet-
ter across the bonding interface to the tooth, potentially
reinforcing weakened tooth structure.14
Mandibular molars were selected for the study because
these teeth have a high incidence of caries and are sub-
jected to high occlusal forces. An endodontically-treated
tooth with an extensive MOD cavity preparation may un-
Vol 15, No 2, 2013
Khan et al
Table 1 Fracture strength by group
Groups Fracture load (N)
Minimum Maximum Mean SD
1 1365.90 1866.50 1598.84d 168.36
2 355.50 421.00 393.79a 24.48
3 502.60 857.60 699.71b 114.57
4 473.20 926.30 729.34b 168.00
5 767.60 1340.50 958.64c 162.79
6 744.40 1290.50 913.20c 151.35
Group definitions: 1: control. 2: endodontic access, standard MOD cavi-
ties were prepared, left unrestored. 3: endodontic access, standard
MOD cavities were prepared, teeth restored with composite resin.
4: endodontic access, standard MOD cavities were prepared, flowable
composite resin (Venus, Heraeus Kulzer) liner placed before restoring
with composite resin. 5: endodontic access, standard MOD cavities were
prepared, leno-woven ultrahigh molecular weight polyethylene ribbon
fiber inserted in flowable resin and adapted to cavity, then restored with
composite resin. 6: endodontic access, standard MOD cavities were pre-
pared, translucent glass fiber adapted over flowable resin, restored with
composite resin. Different superscript letters between subgroups denote
significance at the 5% level (post-hoc test).
dergo cuspal fracture if restored with amalgam.7 How-
ever, improved fracture resistance of teeth after using
resin composites for MOD restorations has been demon-
strated.10,18
When restoring with composite, many factors may af-
fect the resistance of a tooth to vertical and/or cuspal
fracture, such as cavity dimensions20 or the restorative
systems utilized.21 Polymerization shrinkage is a prob-
lem with extensive direct composite restorations. One
of the methods suggested for reducing debonding during
polymerization shrinkage is to apply a low viscosity flow-
able resin to act as a “stress breaker”.33 Hence, in this
study, the effect of flowable composite as an “elastic
buffer” under a composite resin was evaluated; it was
found that the use of flowable composite liner did not
increase fracture strength. Similar results were shown in
previous studies by Belli et al.4,6 This phenomenon can be
explained due to the presence of a weak interaction and
gap formation between the flowable resin and restorative
resin.5 The presence of a void between the flowable and
hybrid composite would permit some flexure of the restor-
ation and subsequent flaw formation and fracture.5
The development of fiber-reinforced composite (FRC)
technology has brought a new material into the realm of
metal-free, adhesive esthetic dentistry. Many investiga-
tors have confirmed the reinforcing effect of fibers on dif-
ferent polymer types.2,16 The explanation for this increase
was the transfer of stress from the weak polymer matrix
to fibers that have a high tensile strength.22
Many fiber types and architectures are available for
clinical use to reinforce dental composites. Currently, ul-
trahigh molecular weight polyethylene fibers (UHMWPE)
and glass fibers are being used extensively. Continuous
169
Khan et al
bidirectional fibers (woven, mesh type) reinforce the poly-
mer equally in two directions. The use of woven fibers pro-
vides the orthotropic properties in a plane.31 Thus, mesh
fibers of polyethylene and glass fibers were selected for
the study.
Ribbond (Ribbond; Seattle, WA, USA) is a leno-woven
ultrahigh molecular weight polyethylene ribbon. Ribbond
fibers exhibit high tensile strength, modulus of elastic-
ity, and fracture toughness, and also conform well to the
contours of the teeth. It is also biocompatible and has
excellent optical properties.25
Glass fibers are used in different forms to strengthen
dental composites; woven glass-ribbon fabrics are most
commonly used. Vectris is a continuous bidirectional fiber
(woven type) based on the E-glass fiber system. The E-
glass fiber system is based on the SiO2-Al2O3-CaO-MgO
component, which has good glass-forming ability. The
glass fibers used in this study consisted of both linear
and cross-linked polymer phases. The linear phase in this
material, which is polymethylmethacrylate (PMMA), is dis-
solved using bis-GMA, as shown by Lassila et al.17 Thus,
in this study, flowable composite resin (FCR) was used in
conjunction with glass fibers.
Although the literature contains many studies with
fiber-reinforced composite (FRC), the comparison between
glass and polyethylene fibers as an “elastic buffer” to
reduce the polymerization shrinkage has not been suf-
ficiently evaluated.
In the present study, the fracture test was performed by
applying axial forces to the center of the occlusal surface.
The teeth were subjected to vertical compressive loading
with a stainless steel sphere 6 mm in diameter. Numerous
studies have shown that the use of a 6-mm steel sphere
for resistance to fracture testing was ideal for molars, be-
cause it contacts the functional and nonfunctional cusps
in positions close to those found clinically.9,28 The force
needed to fracture the samples was recorded in Newtons.
Although microcrack formation leads to the eventual fail-
ure of the restoration, the present study recorded the
peak-load fracture in order to test the fracture resistance.
The results of the current study demonstrate that
the fracture resistance of teeth restored with Ribbond
and glass fiber was much higher than the other restored
groups. However, the difference between the two fiber
groups was statistically not significant.
Polyethylene fibers show a mean fracture resistance
of 958.6 N, significantly higher than teeth restored with
only composite resin (group 3). Other authors have re-
cently reported similar outcomes.6,26,28 The open geom-
etry of the tightly woven leno-weave allows for complete
infusion and “wet-out” of the fibers by the resin. To
reduce the fiber’s superficial tension, gas plasma treat-
ment has been used, ensuring a good bond to composite
materials.34 The leno-weave fiber possesses the proper-
ties of crack resistance and deflection as well as resist-
ance to shifting within the resin matrix. Meiers et al19
stated that the higher modulus of elasticity and lower
flexural modulus of the polyethylene fiber may have a
modifying effect on the developing interfacial stresses
along the etched enamel/resin boundary.
170
The glass fiber group also demonstrated a high fracture
resistance in the present study. This is in accordance with
a study done by Oskoee et al.23 The glass fiber mesh
could be easily cut and embedded into dental composite
without any major structural alteration; the fiber bundles
maintain their orientation and do not separate from each
other when closely adapted to the contours of the teeth.
Thus, the favorable elastic modulus and the interwoven
nature of a fabric distribute the load over a wider area,
thereby decreasing the stress levels. These fibers con-
taining PMMA resin additionally form chemical bonds with
the initial increment of the composite, and therefore resist
the composite pulling away from the margins. Thus, they
have a strengthening effect on the composite margins.
In the present study, both fiber groups showed sig-
nificantly high fracture resistance. Both polyethylene and
glass fibers have an inherent crack-stopping property.
This was theorized on the concept that the presence of
the fiber network would create a change in the stress
dynamics at the restorative/adhesive interface. They
also increase the resistance to dimensional changes
or deformation.11 In addition, these fibers replace part
of the composite increment, resulting in a decrease in
the overall volumetric polymerization shrinkage of the
composite.
In the present study, a static loading method was used
to test the samples for fracture resistance. A further study
using a dynamic method to test the fatigue strength is
planned to strengthen the results. Moreover, a larger
sample size may have been able to demonstrate a differ-
ence among the two fiber groups.
CONCLUSION
Under the conditions of this in vitro study, it can be in-
ferred that composite resin restoration of the prepared
cavities increases the fracture resistance of root-filled
molars because of its reinforcing effect on the tooth
structure. Use of flowable composite as a liner under
the composite restoration did not significantly increase
the fracture resistance of root-filled molars because of
the weak interaction and gap formation between the
flowable composite and restorative resin. Finally, inser-
tion of a polyethylene ribbon fiber or a glass fiber be-
neath composite resin in root-filled molars with a MOD
preparation significantly increased fracture strength with
no statistical difference between the two groups. Thus,
both the polyethylene and glass fibers prove their role
as a “stress breaker” in counteracting the polymeriza-
tion shrinkage stresses of composite core buildup res-
torations.
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171